Examination Supervisor Form (to be completed by proposed Examination Supervisor)

Please ensure that the following contact information you submit is accurate. The examination(s) must be sent directly to the educational institution address.

Last Name

First Name

Address 1 (work)

Address 2 (work)

Address 3 (work)

Postal Code

Telephone (Home)

Telephone (Work)

FAX

Work Email Address

Occupation

Employer

Employer_WebsiteDO NOT INCLUDE THE "HTTP://" PART OF THE ADDRESS.

Do you have an affiliation with this student?

NO YES

If you answered YES What is your affiliation? (provide specific details if applicable)

Have you supervised exams for Memorial University in previous semesters?

NO YES

Provide specific days of the week(ex. Mon-Fri, Thurs-Sun, etc).

What is the name of the school where you will supervise examinations?

Will the supervisor be present in the room at all times while the student is writing the exam? NO YES

Student's Name

Additional Comments/Instructions

This information is intended for the use of the recipient to whom it is addressed, and contains confidential, personal, and/or privileged information.

I agree to keep all information confidential and will not share or discuss with any third party

All the materials you receive in exam packages should be returned to Centre for Innovation in Teaching and Learning (CITL).

Contract

I agree to supervise exams for the above-named student. I will ensure that examination(s) are written on the date(s) assigned by Centre for Innovation in Teaching and Learning (CITL) and that the examination(s) are kept in a secure place until that date. I agree to administer the examination(s) according to the regulations provided by Memorial University and to return the written examination(s) to CITL within 24 hours of completion. I certify that I am not related to the above-named student nor am I a co-worker or supervisor of this student. I do not reside at the same address as the student, nor am I currently registered in a course at Memorial University.

The amount paid to examination supervisors is $15 Canadian per hour of examination time. I agree to direct bill Memorial University for this hourly charge. In addition, the University will reimburse examination supervisors for charges incurred in shipping exams. Any additional costs, including charges for room rentals, are the responsibility of the student. I agree to collect from the student any additional charges, including any amount that is in excess of the $15 per hour (Canadian).

I have read and agree to the conditions of the above contract

NOTICE

"Memorial University protects your privacy and maintains the confidentiality
of your personal information. The information requested in this form is
collected under the authority of the Memorial University Act (RSNL 1990
Chapter M-7) and is used for the purposes of academic and student services
administration. Questions about the collection and use of this information
may be directed to the Services Coordinator at 709-864-3532."